Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Sunday, March 04, 2007

Anonymous makes a good point in a comment on my "Can't Stop Poking it With a Stick" post:

EMTALA dates from what, the mid 1980s. Didn't youknow about it when you were choosing your specialty? Knowing about it, why didyou choose a specialty where you're most likely to be hit hardest byit?

My answer was long and rambling and you may read it if you wish, but the easy answer is that Emergency Medicine interested me and was the best fit for my inquisitiveness and short attention span. Jack of all trades master of none. That's me.

Here I would like to compile a list of the unintended consequences of the unfunded federal mandate called EMTALA. To my nursing and physician colleagues please add to the list as you see fit.

My primary objection is voiced much more eloquently at "Movin' Meat" (click title above to see his EMTALA post) and is, essentially, that EMTALA is nothing more than theft by legislative fiat. Under penalty of law we MUST see all patients with an "emergency condition" or face jail or financial loss. It does not apply to dentists, chiropractors, massage therapists, aromatherapists, shamans etc... Here is my short list of what flows from this communistic scheme...

1. Cost Shifting: Medical treatment has cost. Someone pays. EMTALA has shifted the burden of payment for the uninsured onto the insured, taxpayers, insurance companies, and doctors. As a result, it's harder to get insurance, our taxes go higher, the number of uninsured has skyrocketed, insurance rates have skyrocketed, and doctors make less money. I know, poor rich doctor right? I'm 46 and finished paying off my school loans five years ago. If I keep at this for another 15 years I can retire comfortably (unless I screw up at work and get sued). If you want to get rich and sleep well then stay the hell away from medicine. If you want to work in a tremendously demanding field with high pressure, responsibilities that increase every year, and pay that does not keep pace with inflation then medicine is perfect for you!

2. Insurance Tomfoolery: Since I don't work in the insurance industry I will only say that with my current insurance a medicine that I take daily costs $90 per month cash and $93 per month with my insurance. My taxes, even with the "Bush Tax Cuts" are 33% of my income. I work harder and faster for less money every year, and, when I find an out to a less taxing (in all senses) profession I will take it. I am not alone.

3. Physician Shortages: Speaking of doctors leaving the profession lots of irreplaceable talent in medicine is opting out of the system. Surgeons train for AT LEAST five years, and that's just to do general surgery. Their debt load out of residency can approach $300,000. To do a surgical sub-specialty add $100,000 of debt, a divorce or two, and three more years in the black hole. You can replace an office manager by posting an ad on Monster.com, you can not replace a neurosurgeon or cardiothoracic surgeon if no one is willing to go through residency hell. In other words, these fine humans have to, at least at some point, believe that the sacrifice will be worth it and not just in financial terms.

Now, with EMTALA, specialty surgeons are dropping their hospital privileges like hot potatoes and opening up surgical centers. I don't blame them, if they sign on with a hospital then they have to take ED call and any drunk asshole who falls off a bar stool and breaks his leg at 3am on a Sunday has just blown the whole day for the orthopedist on call. All his paying patients are bumped from his schedule so he can take care of the patient in the ED. I live in a town of 200,000. We have five orthopedic surgeons. Five years ago we had six. Next year we will have four.

We do, in fact, have three plastic surgeons in town. None will maintain privileges at the hospital. So now your complicated ear laceration will be repaired by, well, me. I'm not bad, but I'm no plastic surgeon.

Interventional cardiologists? We have one. We have been trying to recruit another for three years. No one will come here because of the Emergency Department and the burden it would place on them to give away care. How much is it worth to save a patient dying from a heart attack? The answer is a number greater than zero, really, it is.

4. Increased Demand for ED services: The uninsured public has learned over the years that the ED is free (and that you don't have to be a US citizen to take advantage of it). What I mean is that when they are treated in the ED they get a bill which they never pay. Since they have no money and no credit there is no way to collect and no consequences for using the EMERGENCY DEPARTMENT as the "SNIFFLE AND WORK EXCUSE DEPARTMENT". Our collections, a bit below average for Emergency Departments across the country, are about 28 cents on the dollar.

5. Encouragment of Personal Irresponsibility: Because the uninsured public has come to rely on the free care we provide their health maintenance needs are not met. Consequently I often see patients whose untreated hypertension has resulted in a stroke or heart attack. Often there is no one to blame here but the patient and EMTALA. If you had to choose paying a few hundred dollars a year to see your Internist or FP to manage your chronic medical conditions AND you had to pay for your medicine wouldn't it be really easy to fall into thinking that it doesn't matter really because if you get into trouble you can just go to the ED? Believe it or not this truly is the way people think. If you doubt me just look at the number of people who still smoke and don't give me any crap about "evil tobacco companies". People choose and at least in the ED they have usually chosen poorly. Who should pay for this? EMTALA doesn't say and its silence is deafening.

6. ED Overload: Because the ED is the place of first and last resort now for huge numbers of uninsured we physicians are battered by the need to sort through piles of the unsick so that we don't miss anyone who truly has an emergency. In our ED we saw 70,000 patients last year. It was renovated in 1990 to accommodate 25,000 patient per year. Oh, and by the way, you better not miss anything in one of the "unsick" or you will get a letter from an attorney, or, what's often worse, a patient complaint.

7. Nursing Shortages: Because of the now ridiculous demands of the ED, nurses are fleeing. They are not paid on a production basis. They are not supposed to have more than a few patients at one time and they are supposed to focus on the patients they have. The nurses save our asses time and again because they have good clinical judgement AND they spend a lot more time with our patients than we do. It is routine now at my institution to lose a nurse a month and, if they can be replaced, they are replaced by newbies. The only way to make the ED work now is for nurses to cover each other and see each other's patients while they do all manner of extraneous tasks (patient transportation to the floor for instance). I wouldn't work one day in the ED as a nurse. It's unsafe. Congratulations voting public, your government representatives have legislated you into a "guinea pig for newbie nurses" status at many of our EDs. Now before I get a lot of hate mail from nurses let me be the first to say that there are many great newbie nurses out there, but that all of us need to learn to drink from the fire hose that is the ED under supervision.

8. Health Care as a Right: EMTALA, like all the other wonderfully successful government entitlement programs has, WOW, produced a sense of entitlement in the uninsured! As a direct result of EMTALA many people who can least afford to get sick do not think it is their responsibility anymore to either make good choices about their health or pay for the consequences of their bad choices.

9. Bad Math:EMTALA says 2 does not equal 2. You see, because of the need to cost shift, doctors are now payed based on government and insurance company fee schedules. These basically say that a $900 procedure is reimbursed at, say, $250. Now that's new math! I am looking forward to the application of EMTALA to the auto industry so I can finally buy a BMW.

10. Bureaucratic Asexual Reproduction: Lots of full time government jobs created to police EMTALA. Lots of lawyers happy. Lots of politicians elected for giving away other people's stuff. It's easy, after all, to give away other people's stuff, especially those pretentious, rich, selfish doctors. Many of my patients do not deserve the care they get on the back of the taxpayer, but as William Muney (Clint Eastwood) says in Unforgiven, "Deserving's got nothin' to do with it."

24 comments:

Leading to overutilization of imaging/tests/referrals to ensure that you CYA and avoid lawsuits.Which further increases the costs of the care that is not funded (and as noted in #1 is passed on to those of us insured taxpayers.)

(Am not sure about this, but think that EMTALA may have also encouraged more illegals to cross the border to have their anchor babies. A decade ago 40% of Medi-Cal (medicaid) mothers giving birth in LA county were illegals.)

Here is another point. As we see all patients as a government mandate regardless of payee status, we are de facto government employees. When we are sued by these patients we should be covered just like VA doctors or other government employees and these patients should in fact be suing the U.S. government. But this is not the case.

When I was in training, Arizona's equivalent of medicaid started providing free tylenol to parents in the ED. This was thought to be a compassionate move.

Consequence: marked increase in febrile seizure and skyrocketing visits for colds by those who were now disincentivized to pay for $3 of tylenol. When I dumped the tylenol bottles into the purse of these moms, I usually saw way more then $3 worth of cigarettes.

Well View from the Trekant...I witnessed a febrile seizure at an understaffed hospital clinic (where I was a paying parent on vacation on Christmas Eve)...the ER was a longer wait and had no pediatrician...a little Tylenol would've done a world of good for that little boy. Luckily we had our own Tylenol.

Not all people who avoid primary care do so out of the desire to shaft the ED. I know of several instances where people have avoided ALL medical care, due to cost, until it becomes a matter of going to the Emergency Department or dying that night. It's not as simple as people being jerks.

Straw man. The cost of coming to the ED at the last minute is exponentially more than taking care preventatively. Also, I am not suggesting that people have any concept or intent of "shafting the ED", what I'm saying is that by separating cost from care the government has, WOW, increased demand for the care. If people are not forced to pay something, anything for a service, then why budget for it and why save for it and why plan for it?

Could you just run it past me again? Just why do you think basic health care should not be free to the patient? Lots of people in the world disagree with you. In the rest of the civilised world we pay our taxes because we think that basic protection for those with little or no money is a good thing. Yes, the government should pay those who deliver the care properly, but that is a separate argument from whether there should be free health care.

To be really blunt, this is one reason why many of us don't count the US into the definition of "the civilised world". It also may explain the apparent indifference to the suffering of Iraqis, if you are indifferent to the suffering of your fellow Americans. Are you monsters who would charge the poor for the air they breathe if you could?

Sheesh - this is the center of straw man arguments. Can you really argue that people's behavior is driven by the way things are billed?

In my example, we had a stampede of inappropriate ER visits because we gave people incentive to use the ER. Note that these patients were ARIZONA MEDICAID patients - who, free of charge and courtesy of the nice American taxpayer, were using the ER more and giving simple treatments like tylenol for a fever less often directly as a result of our stupid system. They had more extensive benefits, by the way, than I did as a resident putting in an 80+ hour work week.

Their care was paid for by American taxpayers whether the patient went to PCP or to ER.

P.S. Would charge cowardly anonymous trolls for the air they breath. Air is free of co-pay for everyone else. Thank you.

1. There is no such thing as "free" anything. Please consult any basic economics or religious text.2. There is 'right' and 'wrong' (and sometimes shades of grey) and they are not determined by "lots of people in the world". For example, Hilter (German leader circa World War II) was wrong (some have called him 'evil') but was supported by "lots of people in the world". 3. If the government "should pay those who deliver thier care properly" then the care is not free, it's simply paid for by taxpayers. Besides that, if you believe this then you agree with me! The government does not pay anything for those who receive care under EMTALA.4. If you don't count the United States as the LEADER of the civilized world and a beacon of hope for the oppressed then I really don't expect you to be able to comprehend points 1 through 3 above.5. How you tie "indifference to the suffering of Iraqis" to "indifference to the suffering of your fellow Americans" is really neat. Since this discussion is taking place without reference to Iraq you must be in posession of the kind of crystal ball that I use in the ED to evaluate nonsensical people like you (see post entitled "My Crystal Ball").6. If I were "indifferent to the suffering of my fellow Americans" I think I would not be an ED physician don't you? I save lives and put myself at risk for patients even though I never know whether I'm going to get paid for it, and, in fact, get paid about 28 cents on the dollar. I think that puts me out of the "indifferent" category. I wonder if, at your job (if you have one), you would be satisfied with being paid at this rate?7. Charging the poor for the air they breathe? Hmmm. Now that's a super idea and I will bring it up with the trilateralist commision the next time I meet with them.8. Thank you for your post but remember what Mark Twain said, "It is better to keep your mouth closed and let people think you are a fool than to open it and remove all doubt."

It would seem impossible for an educated doctor to be a dumbass, but you have become the consummate example. EMTALA was enacted in order to prevent patient dumping. During the AIDS crisis, gay men and injective drug users were becoming insanely sick with all sorts of horrible diseases. AIDS back then was super expensive to treat and most times the patient died anyway. Many of the AIDS patients were underinsured or totally uninsured. This meant a $100,000 loss for the hospital in some cases, and for groups of people nobody cared about. So hospitals began to patient dump, telling them to go to a nearby hospital or go back home. In one case, a hospital in Florida paid to send an AIDS patient to California simply because they didn't want to be known as a hospital that treats AIDS patients. The patient died when he arrived.

So there you have it, doctors and hospitals shirking their responsibilities. EMTALA is a DUTY LAW. It requires that an emergency room DO ITS DUTY. 20 years later, we have doctors questioning its benefits because they are jaded and they don't want to triage and "stabilize" every drunk, bum, dumbass mother, insane person, and moron who walks through the door. TOUGH TITTY.

1. If you wanted to make a lot of money, work in an INVESTMENT BANK. If we wanted to examine it properly, part of the high cost of healthcare is your goddamn salary. MD salaries are 20% of healthcare costs in an average hospital. Malpractice suits are about 5%.

2. What does your insurance bill have to do with EMTALA? Remember, the burden of caring for the uninsured is absorbed by the hospital. Okay, but what makes your insurance bill so high? Well studies show that nothing ties more directly to the rise of insurance premiums than the RISE AND FALL OF THE STOCK MARKET. Insurance companies invest their profits in the stock market. When the stock market goes down, they lose money. The shareholders don't like to lose money, so what do they do? They UP THE RATES to make more money. The end. If you don't like it, talk to your local congresswoman.

3. Neurosurgeons and Cardio surgeons are not under any sort of shortage. What is there a shortage of? OB/GYN doctors, because no one wants to have an unhealthy baby and they sue like crazy. You think an orthopedic surgeon didn't have to treat some drunk asshole at 3AM back in the 70's before EMTALA??? You think an interventional cardiologist doesn't want to work in the ED because it will force him to give away care? You are out of your flipping gourd. All specialty doctors know they make more money in private practice. How much money a doctor makes performing in the ED is set by the administration of your hospital. If the salary is not to anybodies liking, it has nothing to do with EMTALA. EMTALA does not force anybody to "give away" care. Guess what, honeybunch. If you get paid, YOU are not giving away care. The hospital is.

4, 5, 6. I cannot argue that forcing an ER to treat every stupid thing that comes through the door has not encouraged some people to be total babies. Unfortunately it is Managements job to figure out more effective forms of triage, including using PA's to handle the less serious cases. What EMTALA has to do with untreated hypertension is a cognitive leap that is beyond me, i guess. That hypertension would not be treated one way or the other for an uninsured person. The only difference is now when they have a heart attack they can be seen with the same care as someone who is insured.

7. The nursing shortage has NOTHING TO DO WITH EMTALA. It has to do with the crummy status of nurses in hospitals, the lame pay, the horrible work (which was heinous before EMTALA), and the fact that women are going into career fields that were previously men-only. However, men are not streaming into nursing.

8. Your work in the ED has clearly made you very jaded, and this is something that is common among any ED employee I have ever met. They are tired of dealing with the scum of the earth. Well sorry honey, but it is not the governments job (yet) to force people to take care of themselves. It is their job to force you to take care of them, so HA HA. Oh, and healthcare IS a right. Get used to it.

9. How you are paid is your hospital talking. Go somewhere else.

10. Again, your precious golden nuggets of excellent care are being torn from you by this evil law, but blame the generation of doctors before you who shirked their responsibilites. It's their fault this law is up. However, don't confuse this law and ALL THE OTHER issues that plague healthcare, because many of the ones you have mentioned are unrelated.

A few minor quibbles though, my original post was entitled "The Unintended Consequences of EMTALA" and had nothing to do with its intent, which, as you so correclty point out, was to prevent "patient dumping".

I can not argue with "TOUGH TITTY", point taken.

As I pointed out in a previous post I did not go into medicine to get rich, that is clearly the province of other fields of endeavor in today's America.

As to what my insurance bill has to do with EMTALA please read my entire post.

If we are not short of specialty surgeons please send them to rural America where they are a vanishing breed. I thank you in advance for this information and help.

The cognitive leap involved in how untreated hypertension is linked to EMTALA is clearly explained in the post and I would bore most readers repeating it here.

No doubt the nursing shortage has "NOTHING TO DO WITH EMTALA. It has to do with the crummy status of nurses in hospitals, the lame pay, the horrible work (which was heinous before EMTALA)..." I will just have to take your word for it since you seem to be a font of incontrovertible truths.

As to your point of it not being the government's job, "yet" to force people to take care of themselves, and that "health care IS a right, get used to it!" I again, am instructed by your cogent argument, but if you could simply point out where this right comes from it would help me greatly. In the meantime please say hello to everyone down at the National Socailist Party headquarters.

As to "going somewhere else", again, as I mention in my post, I am, at the earliest opportunity, leaving medicine. Rest easy, I'm sure there will be someone along shortly who is not "jaded" to take my place. They may even be trained in medicine or something like it.

As to your final point I will start blaming the generation of money-grubbing scum that was the "generation of doctors before me" at my earliest convenience.

Finally, one more quibble, the argument you engage in, brimming with anger, is what's known as an 'ad hominem attack'. Always a pleasure to have one of my readers demonstrate for the entire audience the attitude which prevails on the health care consumer side of the market. In other words, thank you for proving my points. Have fun spreading misery today!

If you're planning to leave, a decision I fully respect, that opens a couple questions. You're leaving because you're unhappy with the way things are and have been for about 20 years. And your leaving means the resources used to educate you weren't most effectively used.

What could someone have shown or told you that would have convinced you before medical school (before you went into debt if you did, and so forth) that you would be unhappy, and thus that you shouldn't apply to medical school? What could/should you have learned during your medical schooling to help you choose a specialty you'd be happier with, if any?

When you look around and see other doctors who are unhappy with their profession and want to leave, what traits do they have in common? What traits do doctors who are happy with their profession have? How could medical school admissions boards screen for people with those traits?

I don't think anyone could have done any more than they did to convince me not to go into medicine. I worked with a few doctors prior to medical school all of whom told me that medicine was headed for a crash. Didn't matter, I had opportunites to be a pilot for the Air Force and also I had been accepted to law school when I made my decision to do medicine. What can I say? I felt medicine was my calling and I was not going to stop until I had become a physician.

In terms of choosing a specialty in which I would have been happier I believe I have given the wrong impression. I love the specialty of Emergency Medicine. What I did not and could not appreciate even in residency was that the completion of residency did not translate into a marked decrease in sleep deprivation, anxiety, and frustration. Hence my focus on EMTALA as I see it as the cause for many of these problems.

I believe that if the ED had not been mandated to become the safety net for our entire population for both real and perceived emergencies then I could have shifts which were much more reasonable and focus on my area of expertise, treating medical and surgical emergencies.

To come back to point, I guess if someone had shown me, as I was deciding about residency, that as an emergency physician I would spend 80% of my time on the phone, looking up old records, dealing with angry family members, drug-seekers, frequent fliers, and psychiatric patients then I would have probably gone into dermatology, which, because there are only three dermatologic emergencies (none of which need a dermatologist to diagnose and treat), falls outside the scope of EMTALA.

One more thing... If I had understood that outside of a large city or large academic center, that I would be placed in situations where I would be without specialists that I need to complete treatment on my truly emergent patients I might have chosen to stay in a large city or academic center.

For instance, if you come into my ED after a car crash and you have internal injuries then you can not be cared for at my facility. It's not that we don't have surgeons, it's that none of them can or will do trauma surgery cases.

It's then on my shoulders to stabilize you enough to get you an hour down the road and if our helicopter isn't flying then my sphincter tone increases accordingly.

I live in a town of 300,000 and I do not see the lack of specialists improving and I do think it is largely because of EMTALA.

You do not want to be the only pediatric surgeon in town because all of a sudden you own all the uninsured patients in our region that need a pediatric surgeon.

Also, since we don't do these subspecialites at our facility, you don't want to be the first guy to come in and do neurosurgery and have the plaintiffs attorney, on a case that goes south, ask you on the stand why you did X procedure at your facility where it had never been done before when at Y facility one hour down the road they did the procedure every day.

I am not a doctor and disagree with the comments of the doctors regarding the ED and the under insured.What about the ones who cannot get private insurance due to the doctors mistakes that left terrible consequences to the patient?I pay out of my pocket every month a minimum of $800.00 monthly for the mandatory medical care now required due to the docs mistakes.I sense a great deal of hostility to the sick or the not so sick but you chose to do this for a living or excuse me your calling.Talk to the ones like me that thanks for the care has created another set of problems that the caps set on medical malpractice suits can never do enough.I would give anything to be able to sit down and have a normal bowel movement.I would not trade my experience due to the character i have developed.I believe that most of you doctors have a great deal of animosity to the people who believe it or not have no choices.My story is not the usual but i do not think that anyone should go through the things i have been subjected to for the past 7 years due to a mistake the doctor made and his ego was in the way to rectify the problem.Thank God for the trauma surgeons that were called in for my care after the screw up of the original doctors.Complete life support for 3 months,nothing to eat or drink by mouth for 6 months,scared from my neck to my knees,but am thankful that i can walk,hell i am a miracle to be sitting here writing this.I will be forever grateful for Dr. Sidney Vail and Dr. Patrick Ryan my trauma docs.The nurses were my guardian angels and i pray for them all.Why did some of you chose this profession if you feel so superior to the people who need your care?We would be better off without you guys practicing medicine.I have not been able to resume my life that i knew before this doctor did his surgery.Lost my marriage and most everything that i knew as my life.No money can give that back.It can only pay for me to have the medical care that is needed that was not before.I am now uninsurable due to incompetence.I am able to write this now but i now realize how difficult this is to me where as before writing poetry stories was a gift i possessed.I have post traumatic stress disorder now not to mention i am looking at a final surgery to get my abdomen with skin on it.I am tired and it shows in my ability.I have a difficult time with the things that were simple before this and this is the first time that i have vented.Get a grip and be thankful or better yet find a different job if you can't be objective to your patients.You are not God!I would gladly trade with you for one day then maybe you doctors would understand about the frivolous lawsuit as you say that is hurting everyone.What a bunch of bull and no i do not advocate tort reform although i was named as a reason for it to be passed.Most who have been to the depths of hell as i have due to the incompetency of a doctor do not recover the way i do.I had faith in myself and my God.I am very thankful for my pain management doctor who has given relief so that i can have as normal of life without the pain hindering my recovery.My plastic surgeon who has done wonders with a mess that no woman should have to look at due to a removal of an ovary.Thanks for the therapy to vent i needed it.To think i prayed for this incompetent doctor who did not care for me at all.I felt compassion for him and torn inside but thanks to reading the way you really feel about your patients i am now clear on this matter.I will be checking in to read and comment.I have not intentionally meant to offend anyone only my opinion and my take on the various things that i have read.If i were found to be negligent in a car accident that had devastating consequences to somone else i would be put in jail and what happened to me was criminal only it was a doctor and society has a different perspective on this.Until next time keep up the good work all you caring doctors.

There are bad doctors and there are doctors who make mistakes and there are doctors who deserve to lose a negligence lawsuit. However, this post was not about negligence, frivilous lawsuits, or tort reform. It was about EMTALA. Also, I think the doctors posting on this topic are specifically NOT referring to patients like you who obvisouly are sick either from trauma or cancer or whatever, but rather to those who are not sick but wish they were. And, by the way, if you were merely negligent in a car crash and not drunk you would most certainly not be put in jail. I'm sorry you have had a rough go of it and I wish you all the best.

One more thing regarding the penultimate post by anonymous. Dear Anonymous, if you would read a little more from the MD blogs you would run across many posts which demonstrate how we act when we take care of truly sick patients. A post that might interest you and, perhaps, demonstrate the difference can be found here,

You mention "physician shortage". I would be very careful about saying or writing that expression. You have to be aware whom you are helping by even mentioning it.

I absolutely disagree with the notion of physician shortage and believe it is a slick maneuver of the HMOs to have more doctors available and willing to work for less and less.

The power of HMOs came with an oversupply of physicians that we have had in this country since the 1980s. You read correctly: OVERSUPPLY.

The cost of a service is determined by supply and demand. This is so simple that most people forget it, although the sudden rise of gas prices after hurricane Katrina should have reminded everybody. Physician earning power has dropped to about 1/3 of what it was in the mid eighties. Yes, the colleagues that were watching the first season of Miami Vice, if they had time, earned three times as much as we do.

That alone is proof of an oversupply. Studies about future demand are all nice and well. You can look at supposed demand as uch as you want, the basic economic truth is that the payments for physicians have decreased dramatically. 20 years ago an ObGyn earned 400 K and a very nice home in the best area of Boston cost about 400K. Nowadays the very same house costs 1.6-2 million and the same ObGyn (working a lot harder and seeing about twice the number of patients) earns 200K. Do the math. That means that we have an oversupply of physicians!

They only people interested in more physicians are the HMOs - in an attempt to lower the reimbursements. The HMOs are the ones who talk up a "future shortage of physicians". There is no such thing. The HMOs just need more doctors to be able to continue paying less and less.

Do not buy into the myth of "physician shortage", there is no such thing, it is pure propaganda. What they are saying is: we want to continue to pay you too little, but we want you to live in not so attractive places and work harder for less. What that talk of physician shortage means is: We do not want to do what the market asks us to do, instead we want to continue to pay what little we have been paying! There is one solution for any "physician shortage" - increase pay until they come! It's called "market economy".

There is no good way of planning physician supply. Who knows what will happen tomorrow and how it will impact physician supply and demand? Maybe we will find the gene for motivation to exercise or the gene for weight and obesity and the manipulation of that gene will make all the heart diseases shrink to 5% of what they are now?

And, did those glorious predictions of need for healthcare consider that we could increase the number of nurse practitioners for the routine work and let physicians do the unusual and difficult things - as it should be???

Planning physician supply 20-25 years into the future? Maybe another Internet style change will surprise us. Who would have predicted the impact of the internet on our daily lives 25 years ago? When considering predictions for the future, do you remember what 60's thought the cars of the future were going to look like? There were pictures of large ship like cars with fins, rotating seats, driving fully automatically...Just what we have now.

So, you think we can foresee the demand for physicians in 25 years? What about foreseeing the ability to pay all those physicians? Have they considered that? Aaaaahhhh, no, not that point, we will just divide the money that is available among more people.....

After I see the income of physicians steadily rising above inflation for 5-10 yeas, and after we have made up (!) for what we have lost in the last 20 years, then, and only then, am willing to believe that we need to train more physicians. NEVER BEFORE THAT. Before that it is all HMO propaganda to me.

I cannot emphasize it enough. The price of a product or service is determined by supply and demand. The HMO's do not change that. They will give you higher reimbursements when they feel they cannot get enough "access" for "their members". In Oklahoma, reimbursements are about twice as high as in, let's say Massachusetts, even though the cost of living is a lot higher in MA. Do I have to say more about supply and demand?It is supply and demand, it's market economy. Period. We have an oversupply of physicians. Period. And I do not need any study or studies with complicated calculations of "need" in the future. The "need" is endless - everybody would just looooove to have a dozen doctors standing by 24 hours a day! Just ask them.Supply and demand, supply and demand, supply and demand. Repeat after me...Matthias Muenzer, MD

i disagree. i WISH the health care industry was governed solely by supply and demand. as it stands here is how the 'business' of medicine works...

1. you come to see me as you are ill2. you are an illegal alien or simply uninsured or underinsured3. i tell you you are having a heart attack4. you say 'oh no, what do i do, i can't pay for treatement'5. i say, 'no problem we'll treat you anyway', and we do6. a bill is generated by a billing company based on my chart7. it is sent somewhere8. there is no payment9. a snowflake falls in siberia10. ms. smith pays her taxes like she always does11. the government takes some money from a recent drug bust in miami, some money from miss smith, and borrows some money from 'future revenues'12. fee schedules are consulted13. anna nicole smith remains dead14. a magical number is agreed upon that will constitute 'payment' of my charges.15. two asteroids pass silently in space16. i get a check from my comany for 26 cents on the dollar for my billed charges to the patient17. the patient returns to mexico18. my health care premiums go up19. the demand for the above free health care increases20. the supply of doctors willing to deliver it decreases21. cardiothoracic surgery programs can not fill their slots22. medical school applications decrease.23. the government looks at this great success and wants to make all health care free.

now exactly where is the supply and demand? it's in every industry but medicine that's where.

It looks like this boils down to a question of where the liability for healthcare should reside.

I'm torn. I've worked my entire life and have consistently had reasonable healthcare, and great doctors.

OTOH, I worry that a pandemic could spread rapidly through an uninsured population that can't afford not to go to work....like our office cleaners, whose agency doesn't provide healthcare and skirts the limits on their worker's comp insurance.

Care has to be paid for....but we as a society have to determine whether we are willing to take the significant tax hit required to provide care to everyone, and understand that universal care doesn't include using the ER as a PCP, etc. EMTALA has led to the latter condition, and it's clearly not what it was designed to do....making EMTALA a compassionate half-measure.

And as any parent who's read "Half Magic" to their kid knows, half-measures have more unintended consequences than we can foresee.

supply and demand go to hell when free market goes out the window. when the gvt becomes the one and only physician employer, it can pay them as much as it wants, as they have no alternative but to take whatever money the gvt decides their services are worth. that in turn forces entire profession to form unions to counterweight the gvt. see europe. see cuba. the more gvt sticks its hand into a free market, the less it is guided by supply and demand. i believe there is a shortage of physicians, some specialties more than others, but salaries have decreased as they are no longer ruled by the supply and demand ratio.